Hemiarthroplasty for Femoral Neck Fractures in Elderly Patients: an Epidemiological Study on Mortality and Periprosthetic Fracture Risk

Case Study

Recent Advances in Arthroplasty © All rights are reserved by Gianluca Canton et al.

ISSN: 2576-6716

*Corresponding author: Dr. Gianluca Canton, Department of medical surgical and health sciences of Trieste University, Orthopaedics and Traumatology Unit, Cattinara Hospital – ASUITS, Trieste, Italy. E-Mail: gcanton84@gmail.com

Received: March 10, 2018; Accepted: March 26, 2018; Published: March 27, 2018

Andrea Nordio, Gianluca Canton, Stefano Zandonà, Chiara Ratti, Luigi MurenaDepartment of medical surgical and health sciences of Trieste University, Orthopaedics and Traumatology Unit, Cattinara Hospital –

ASUITS, Trieste, Italy.

Keywords: Hip Fracture; Periprosthetic Fracture; Cemented Hemiarthroplasty; Uncemented Hemiarthroplasty

Introduction Hip Fracture (HF) is a major public health problem. The incidence

of HF rises dramatically in the elderly population with osteoporosis, occurring in 87% to 96% of cases in people aged over 65 years [1, 2, 3]. An estimated number of more than 6 million HF is expected worldwide in 2050 [4].

The mortality rate after HF is very high especially during the first 3 months, with a 5 to 8 fold increase in risk of all-cause mortality [5]. This trend tends to remain higher after many years [6].

Fractures of the femoral neck and trochanteric region represent about 90% of all HF, with a similar incidence [7, 8]. Some authors identify a 50% incidence within HF for femoral neck fractures (FNF) [9, 10].

The optimal treatment of FNF remains controversial, with hemi-arthroplasty (HA) being the mostly used treatment [11], especially in elderly patients. HA is associated with satisfactory functional recovery, early ambulation [11] and a better clinical outcome compared to screw fixation [12, 13, 14].

Nevertheless, an ongoing controversy regarding HA implanting technique (cemented vs uncemented) is still encountered in the literature. Several studies have shown a better clinical result with cemented stems [15-17], anyway the cardiopulmonary risk associated with the use of bone cement is not negligible [15, 18]. Furthermore, although guidelines suggest the use of the cement for HA [19], uncemented implants remain a diffusely adopted solution for HA implant because of surgical time spare and technical ease for several hip surgeons.

Periprosthetic femur fracture (PPF) is a known but uncommon complication of HA, often occurring in elderly patients with several comorbidities and representing a technical challenge for orthopaedic surgeons.

PPF is associated to significant morbidity and mortality in the aged population [20], thus its correct treatment appears to be crucial.

Although some studies demonstrate a lower risk of PPF in cemented HA [21-25], there is a lack of knowledge regarding the actual epidemiology and clinical features of this event. Aim of the present study is to evaluate a population of femoral neck fracture patients treated with HA, to assess mortality risk and PPF incidence. Possible risk factors for PPF and mortality associated to the event will be secondary aims.

Materials and Methods All patients admitted to Cattinara Hospital of Trieste (Italy)

between January 2010 and December 2015 with diagnosis of FNF treated with HA were considered for the present study.

Data were collected on march 2016 by reviewing the hospital computer storage system and medical records using the ICD-9 (international classification of disease, ninth revision) codes: 820.00, 820.01, 820.02, 820.09, 996.44 for the diagnosis and 81.52 for the procedures.

Two of the authors (A.N. and S.Z.) reviewed the data obtained to identify erroneously included patients. The latter patients and cases with missing data were excluded from the study. For each patient sex, age, ASA (American Society of Anaesthesiologists) score (26), type of anaesthesia, surgical approach, duration of surgery, destination of discharge and number of medications at discharge were recorded.

Patients with an unknown number of medications at discharge and/or unknown ASA score were not excluded from the study but they were not considered in the statistical analysis.

Finally, the use of bone cement was recorded, dividing the population in cemented and uncemented cases.

Follow-up was identified as the time lapse from HA implant and data collection for living patients and as the time lapse from HA implant and death for the others.

Survival curve was calculated and correlated to sex, age and use of cement at different time points (within 7 days, 30 days, 1 year, 5 years).

All PPFs occurred to the population in exam during the study period were recorded. The PPF pattern was classified according to the Vancouver classification system [27]. For all PPF cases the above mentioned demographic and clinical parameters were newly recorded, together with the type of surgical or conservative treatment. Clinical and demographic data were analysed in order to identify possible risk factors for PPF, with particular focus on cement use.

Recent Adv Arthroplast, 2018 Volume 2(1): 46 - 54

Andrea N, Gianluca C, Stefano Z, Chiara R, Luigi M. Hemiarthroplasty for femoral neck fractures in elderly patients: an epidemiological study on mortality and periprosthetic fracture risk. Recent Adv Arthroplast. 2018; 2(1): 46-54.

Statistical analysis

Statistical analysis was performed using the IBM SPSS® statistics software.

Mantel–Haenszel odds ratio (MH-OR) with 95% CI was calculated for all the variables present in the study. Subsequently a logistic regression analysis was used for the significant variables. Kaplan-Meier survival curves were obtained from different variables (sex, age, cement use) and compared with the log rank test.

Results

The population in exam counted 1335 patients treated with HA between January 2010 and December 2015 for FNF.

Data regarding demographical and clinical parameters for the whole population are shown in table 1.

Sex distribution demonstrated a prevalence of female sex, with 77% (N=1029) of cases occurring in female and 23% (N=306) in male patients. Mean age of the population was 85.02 years (range 48-105). The mean age in the male group was lower than the female one, respectively 83.7 in male sex (range 51-105) and 85.4 (range 48-101) in female sex.

Total n=1335 (1,0)

Cemented n=178 (0,13)

Uncemented n=1157 (0,87)

PPF n=15 (1,1)

Age 85,0 (68-105) 87 (67-103) 84,7 (68,105) 84,6 (78,94)

Sex M 306 35 271 4

F 1029 143 886 11

ASA score Unknown 293 35 258 3 1 2 0 2 0

2 315 42 273 4 3 701 98 603 8

4 24 3 21 0 Anesthesia Spinal 1217 152 1065 14

General 117 26 91 1 Time of surgery (min)

70,6 (38-180)

84,7 (45-180)

68,3 (38-180)

70,13 (50-,105)

Discharge Home 415 57 358 6 Institutional care 721 99 622 8 Rehabilitation Institute 137 17 120 1 Death before discharge

63 5 58 0

N° of medications Unknown 369 56 313 0 <10 700 99 601 14

≥ 10 266 23 243 1 7)

Table 1: Data regarding demographical and clinical parameters for the whole population

The predominant ASA score was 3 (52% N= 701) followed by 2 (24% N=315), 4 (2% N= 24) and 1 (only 2 patients).

Hemiarthroplasty was performed under spinal anaesthesia in 91% of cases (N=1217) and under general anaesthesia in the remaining 9% (N=117). The average duration of surgical intervention was 70.6 (range 180-38) minutes.

Institutional care was the destination after discharge in 54% of cases (N=721), and the 52% (N= 700) had less than ten medications at the time of discharge.

All the HA were performed with a lateral approach according to Hardinge. The largely most common stem fixation technique was uncemented (87%, N=1157).

When considering stem fixation technique, the cemented group showed a predominant female sex (80%, N= 143), an average age of 87 years (range 103-57), and a prevalent ASA score of 3 (55% N= 98). Spinal anaesthesia was performed in 85% (N=152) of cemented cases with an average time of surgery of 84.7 minutes (range 180-45). Institutional care was the prevalent destination after discharge (56% N=99), and the 56% (N=99) of patients with a cemented HA were discharged with less than ten medications.

Recent Adv Arthroplast, 2018 Volume 2(1): 47 - 54

Dependent variables

Discharged at home

Discharged at istitutional care

Discharged at rehabilitation institute

ASA2 ASA3 ASA4 N of medications <10

Death before discharged

Death Within 7 days

Death between 8-30 days

Death between 1 month- 1 year

Death after 1 year

PPF

Independent variables

Odds ratio

P <0.05

Odds ratio

Odds ratio

Odds ratio

P <0.05

P <0.05

P <0.05

Odds ratio

P <0.05

Odds ratio

P <0.05

Odds ratio

P <0.05

Odds ratio

P <0.05

Odds ratio

P <0.05

Odds ratio

P <0.05

Odds ratio

P <0.05

Odds ratio

P <0.05

Odds ratio

P <0.05

Sex (male) 0,90 (0,68-1,19)

X 0,77 (0,60- 0,99)

✓ 1,22 (0,82-1,83)

X 0,50 (0,35-0,70)

✓ 1,75 (1,35-2,28)

✓ 2,05 (0,89-4,73)

X 0,65 (0,50-0,84)

✓ 3,39 (2,02-5,67)

✓ 4,26 (1,13-15,95)

✓ 2,45 (1,38-4,35)

✓ 1,77 (1,33-2,35)

✓ 1,16 (0,86-1,57)

X 0,80 (0,54-1,18)

X

Age >85 0,71 (0,56- 0,90)

✓ 0,91 (0,53-1,55)

X 3,33 (2,27- 4,88)

✓ 1,45 (1,113-1,87)

✓ 0,85 (0,68-1,05)

X 0,93 (0,41- 2,11)

X 0,98 (0,79-1,21)

X 2,62 (0,65- 10,55)

X 0,23 (0,10- 0,49)

✓ 0,70 (0,54- 0,91)

✓ 0,76 (0,58-

0,99)

✓ Not calculable

Cemented stem

1,07 (0,78-1,48)

X 0,91 (0,53-1,55)

X 0,55 (0,22-1,41)

X 3,28 (0,81-13,26)

X 1,41 (0,67-2,95)

X 1,00 (0,68-1,45)

X 1,13 (0,78-

1,64 )

X 1,00 (0,22-4,46)

X

Dependent variables

Discharged at home

Discharged at istitutional care

Discharged at rehabilitation institute

ASA2 ASA3 N of medications <10

Death before discharged

Death Within 7 days

Death between 8-30 days

Death between 1 month- 1 year

Death after 1 year

Indipendent variables

MLR P < 0.05

MLR P < 0.05

MLR P < 0.05

MLR P < 0.05

MLR P < 0.05

MLR P < 0.05

MLR P < 0.05

MLR P < 0.05

MLR P < 0.05

MLR P < 0.05

MLR P < 0.05

Sex (male) 0,90 (0,68-1,18)

X 0,62 (0,41-0,95)

✓ 1,41(1,02-1,95)

✓ 0,75 (0,57-0,98)

✓ 2,68 (1,52-4,71)

✓ 3,73 (0,97-14,26)

X 2,09 (1,13-3,86)

✓ 1,35 (0,95-1,93)

X

Age > 85 yrs 0,84 (0,65- 1,08)

X 2,58 (1,72- 3,86)

✓ 0,11 (0.03- 0,38)

✓ 0,42 (0,16- 1,09)

X 0,44 (0,17- 1,14)

X

The duration of surgery was shorter, mean 68.3 minutes (range 180-38).

‘<10’ [Tables 2, 3]. Moreover, the variable male sex was significantly correlated with ‘death’ and ‘death between 8 and 30 days’ [Tables 2, 3]. he Mantel-Haenszel odds ratio test and logistic regression analysis also demonstrated that ‘ASA 3’ and ‘age > 85 years’ were risk factors for the outcome ‘death’ while ‘discharged in rehabilitation institute’ and ‘<10 medications’ resulted to have a protective role on the same outcome [Table 4].

The uncemented group did not differ significantly in terms of age, sex, prevalent ASA, type of anaesthesia, destination after discharge and number of medications at the time of discharge.

Table 2: Odds-ratio (Mantel-Haenszel method) count with a confidence range of 95% for the variables sex (female sex = 0 male sex = 1), age (< 85yrs =0, >85 yrs = 1), cemented stem (uncemented stem = 0 cemented stem = 1).

Table 3: Multinomial logistic regression (MLR) for the variables resulted to be significant at the odds-ratio count (Mantel-Haenszel method – see Table 2)

The variable male sex showed a statistically significant positive correlation with ‘ASA3’ and

Andrea N, Gianluca C, Stefano Z, Chiara R, Luigi M. Hemiarthroplasty for femoral neck fractures in elderly patients: an epidemiological study on mortality and periprosthetic fracture risk. Recent Adv Arthroplast. 2018; 2(1): 46-54.

Recent Adv Arthroplast, 2018 Volume 2(1): 48 - 54

Dependent variable Independent

variables

Sex (male) Age >85 Cemented stem

Discharged at home

Discharged at istitutional care

Discharged at rehabilitation institute

ASA2 ASA3 ASA4 N of medications <10

PPF

Death Odds ratio 2,16 (1,66-

2,81)

1,75 (1,40-2,17)

1,22 (0,88-1,67)

1,31 (1,04-1,66)

0,81 (0,65-1,01)

0,30 (0,20-0,45)

0,68 (0,52-0,87)

1,35 (1,09-1,68)

5,08 (1,72-14,95)

0,54 (0,43-0,67)

0,86 (0,13-2,40)

P <0.05 ✓ ✓ X ✓ X ✓ ✓ ✓ ✓ ✓ X

MLR 0,72 (1,23-2,40)

1,59 (1,26-2,00) /// 1,17 (0,92-

1,51) /// 0,33 (0,24-0,55)

0,92 (0,65-1,28)

1,34 (1,01-1,78)

5,41 (1,74-16,80)

0,73 (0,54-

0,98) ///

P <0.05 ✓ ✓ /// X /// ✓ X ✓ ✓ ✓ /// Table 4: Odds-ratio (Mantel-Haenszel method) count with a confidence range of 95% for the variable death (not death = 0, death = 1) and multinomial logistic regression (MLR) for the variables resulted to be significant at the odds-ratio count.

Kaplan-Meier survival curves [Figure 1] obtained for the whole population showed a significant correlation with the variable ‘sex’ (p-value <0.001), with female patients having a lower mortality rate. When Kaplan-Meier curves were analysed separately for male and female sex there was no significant correlation with the variables ‘cemented stem’ and ‘age > 85 years’ (p-values 0.407 and 0.523) [Figures 2-5].

Figure 1: Kaplan meier survival curve of male and female patients populations

Chi-square Df p- value

Log Rank (Mantel-Cox) 38.915 1 P<0.001

Variable mort.7days mort.30days mort.1year mort.5years

Sex

Females 0,4% 3,4% 24,5% 64,6%

Males 1,6% 8.2% 40,6% 78,2%

Image 1: Kaplan meier survival curve of male and female patients populationsImage 1: Kaplan meier survival curve of male and female patients populations

Andrea N, Gianluca C, Stefano Z, Chiara R, Luigi M. Hemiarthroplasty for femoral neck fractures in elderly patients: an epidemiological study on mortality and periprosthetic fracture risk. Recent Adv Arthroplast. 2018; 2(1): 46-54.

Recent Adv Arthroplast, 2018 Volume 2(1): 49 - 54

Chi-square df p-value

Log Rank (Mantel-Cox) 0.689 1 0.407

Variable Cemented mort.7days mort.30days mort.1year mort.5years

Males

No 1,5% 8,1% 40% 78%

Yes 3,6% 8,6% 46,5% 90%

Image 2: Kaplan meier survival curve of the cemented and uncements stem populations – male sex subgroup

Chi-square df p-value

Log Rank (Mantel-Cox) 0.689 1 0.407

Variable Cemented

stem

mort.7days mort.30days mort.1year mort.5years

Female

No 0,3% 2,9% 24% 66%

Yes 1,7% 6,5% 27,4% 63,5%

Figure 3: Kaplan meier survival curve of the cemented and uncements stem populations – female sex subgroup

Andrea N, Gianluca C, Stefano Z, Chiara R, Luigi M. Hemiarthroplasty for femoral neck fractures in elderly patients: an epidemiological study on mortality and periprosthetic fracture risk. Recent Adv Arthroplast. 2018; 2(1): 46-54.

Recent Adv Arthroplast, 2018 Volume 2(1): 50 - 54

Chi-square df p-value

Log Rank (Mantel-Cox) 0.391 1 0.523

Variable Cemented

stem

mort.7days mort.30days mort.1year mort.5years

< 85 years

No 1% 2,5% 22,4% 62,2%

Yes 2% 3,9% 21,7% 47,76%

Figure 4: Kaplan meier survival curve of the cemented and uncements stem populations – age < 85 years subgroup

Chi-square df p-value

Log Rank (Mantel-Cox) 0.391 1 0.523

Variable Cemented

stem

mort.7days mort.3days mort.1year mort.5years

> 85 years

No 0,3% 5,5% 32,5% 74%

Yes 2% 8,8% 36% 75%

Figure 5: Kaplan meier survival curve of the cemented and uncements stem populations – age > 85 years subgroup

Andrea N, Gianluca C, Stefano Z, Chiara R, Luigi M. Hemiarthroplasty for femoral neck fractures in elderly patients: an epidemiological study on mortality and periprosthetic fracture risk. Recent Adv Arthroplast. 2018; 2(1): 46-54.

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Patient Age Sex Days after HA Trauma Fracture type Surgical treatment Implant type Cemented

1 89 F 626 Low energy B1 Conservative PPF Biomet NO

2 92 F 2063 Low energy B2 Stem revision and cerclage wires

PPF Biomet NO

3 91 F 1190 Low energy B1 Conservative PPF Biomet NO

4 92 F 1116 Low energy C Plate and screw fixation PPF Biomet NO

5 87 F 24 Low energy Ag Conservative Avenir Zimmer NO

6 82 M 52 Low energy B1 Cerclage wires Hip Star NO

7 83 F 40 Low energy B1 Plate and screws fixation with cerclage wires

Avenir Zimmer NO

8a 94 F 43 Low energy B1 Plate and screws fixation and cerclage wires

Avenir Zimmer NO

8b 94 F 1208 Low energy B1 Cerclage wires Avenir Zimmer NO

9 83 M 81 Low energy B1 Stem revision Taperloc Biomet NO

10 78 F 1076 Low energy B2 Stem revision Avenir Zimmer NO

11 86 F 380 Low energy B1 Conservative Avenir Zimmer NO

12 89 F 23 Low energy B2 Stem revision Avenir Zimmer NO

13 94 M 16 Low energy B2 Stem revision Taperloc Biomet NO

14 93 M 624 Low energy B2 Cerclage wires Taperloc Biomet NO

15 86 F 245 Low energy B1 Conservative Avenir Zimmer NO

One patient sustained two PPFs, thus 16 cases of PPF were noted. All PPF cases were caused by a minor, low energy trauma.

PPF population counted 73.3% (N= 11) of females and 26.7% (N= 4) of males with a mean age of 84.6 years (range 78-94). Thepredominant ASA score was 3 (53.3% N= 8) and the 93.3% (N= 14) ofthe interventions were made under spinal anaesthesia with an averagesurgical time of 70.13 minutes.

Institutional care was the destination after discharge in 53.3% of cases (N=8), and the 93.3% (N= 14) had less than ten medications at the time of discharge.

All the data regarding PPF population are shown in table 1.

In 20% of cases PPF occurred within thirty days after HA, in 26% of cases between 30 days and 1 year and in the remaining 54% after 1 year.

According to the Vancouver classification, 6.6% (N=1) were Ag fractures, 53.3% (N=9) B1, 23.3% (N=4) B2, 6.6% (N=1) C [Figure 5, 6].

Mortality rate of the PPF population reached 46% at follow-up (7 patients), with death occurring between 31 days and 1 year in 2 cases and after 1 year in the remaining 5 cases.

Mantel-Haenszel odds ratio test for the variables cemented stem, age >85 years and sex did not show a significant correlation with PPF[Table 2].

Kaplan-Meier survival curve was not obtainable for the PPF subgroup because of the small sample size.

Figure 6: Radiographic images of different periprosthetic fractures occurred in the study population classified according to Vancouver classification.

Table 5: Data regarding demographical and clinical parameters for the PPF population

Andrea N, Gianluca C, Stefano Z, Chiara R, Luigi M. Hemiarthroplasty for femoral neck fractures in elderly patients: an epidemiological study on mortality and periprosthetic fracture risk. Recent Adv Arthroplast. 2018; 2(1): 46-54.

Periprosthetic femoral fracture occurred in 1.1% (N=15) of patients, with the 100% of cases occurring around an uncemented stem [Table 5 ].

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Discussion The present study population is characterized by prevalence of

female sex (77%) and advanced mean age (85.02 years), with male patients being meanly younger (85.4 vs 83.7 years). These data are comparable to other literature reports, delineating the most common characteristics of FNF patients [1-6, 28]. Moreover, several como-rbidities, high ASA score and elevate number of medications are often reported in these patients and recognized as risk factors for perioperative morbidity [29, 30]. Indeed, Yeoh and Colleagues [31] found an increment in 30-day mortality rate in patients with ASA score 3-4. Other authors [32-34] reported mortality after 1 year from intervention to be influenced by ASA score. The present study data seem to confirm these findings, with a higher mortality rate at 30 days for ASA 3 and 4 patients. Moreover, statistical analysis demo-nstrated a significant association for ASA 4 with the outcome death.

The present study results also demonstrate a higher mortality rate at different time points and significant association with the outcome death for age >85 years and male sex. The Kaplan-Meier survival curves for the variable sex reached a statistical significance, especially for the mortality rate between 8-30 days from surgery. These findings are comparable to the literature, which reports an association of increased mortality and poorer functional recovery with advanced age [1-4, 35, 36] and a higher mortality rate for male sex [37-39]. A possible explanation for these findings may reside in the worst medical conditions of male patients presenting with FNF. Indeed, male sex demonstrated a significant association with ASA 3 score and negative association with < than 10 medications at discharge in the present study.

As far as stem fixation technique is concerned, the literature generally reports better results for cemented stems in terms of clinical outcome, pain and reoperation rate [15, 21-25]. On the other hand, in the present study surgery duration was significantly longer in cemented cases, which confirms previous literature reports [32, 33]. Moreover, bone cement implant syndrome needs to be taken in account. In the present study, due to its retrospective design, no data regarding bone cement implant syndrome was disposable. Nonetheless, a slightly higher mortality rate in the perioperative period (1 vs 3% within 7 days) was found for cemented case, as other authors previously reported [16, 40]. However, mortality rate for cemented and uncemented implants seems not to differ at mid and long term [16, 39]. Indeed, the present study demonstrates a similar mortality rate in the two groups at 1 year follow up (42% and 46%) and after 1 year (45%). Finally, stem fixation technique did not demonstrate a significant association with the outcome death. In elderly patients treated with HA for FNF periprosthetic femoral fractures can be a serious complication [15-17]. This event is poorly studied in the literature, with a reported incidence which ranges from 0.4% to 4% [16, 17, 21-24]. Thus, the 1.1% incidence of PPF noted in the present study seems to align with previous literature findings. At radiographic analysis, Vancouver B1 and B2 fractures were prevalent (76.6%) in the present study, comparably with what already reported in literature [23, 24].

The low incidence of PPF in FNF patients treated with HA may be due to the low functional demand together with high mortality rate of these patients. However, as in total hip arthroplasty implants, PPF seem to occur in HA patients more often in uncemented implants [16, 17, 21-24]. In fact, all PPF cases reported in the present study population occurred in uncemented implants. However, probably due to the low number of events, the statistical analysis failed to recognize uncemented stem fixation as a risk factor for PPF. Likely, the present study did not demonstrate a significant correlation

higher in PPF patients compared to all HA (0.46 vs 0.50), probably because of the low number of events [17, 22].

of PPF with the variable ‘age >85 years’. Other authors previously failed to demonstrate a significant correlation [17, 43], although advanced age is generally considered a possible risk factor for PPF [41, 42]. On the other hand, previous studies reported a higher mortality rate in PPF patients [17, 22] which was not registered in the present study. In fact, mortality rate did not result to be statistically higher in PPF patients compared to all HA (0.46 vs 0.50), probably because of the low number of events [17, 22].

Conclusion Elderly patients treated with HA for FNF confirm to be a popu-lation with a relevant mortality rate, which demonstrates to be significantly associated with age, male sex and ASA score. PPF represent an infrequent but potentially serious complication of HA implanted for FNF. There is a lack of evidence regarding the effect of PPF on mortality rate. However, advanced age and the use of uncemented stems seem to be risk factors for this event.

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Andrea N, Gianluca C, Stefano Z, Chiara R, Luigi M. Hemiarthroplasty for femoral neck fractures in elderly patients: an epidemiological study on mortality and periprosthetic fracture risk. Recent Adv Arthroplast. 2018; 2(1): 46-54.

Recent Adv Arthroplast, 2018 Volume 2(1): 54 - 54